Applicant Full Name Applicant Address City, State, ZipcodeBusiness Phone Number Home Phone Number E-Mail AddressAre you presently insured? Yes NoIf yes, Insurance Company:Renewal Date:If no, is this a new home purchase? Yes NoYear house was built?If more than 10 years old: Has electric been updated? Yes No Has roof been reshingled? Yes NoWhat is the current market value?What is replacement cost? Have you had ANY loss within the last five years? Yes NoIf yes, please list losses:Date Type of Loss Amount Paid By Ins. Co.Do you have replacement coverage on your home? Yes NoDo you have replacement coverage on your personal contents? Yes NoWhat are your liability limits?What is your deductible? Do you have any animals? Yes NoIf yes, please list: Has Animal Ever Bitten AnyoneType of Animal Yes/NoDo you have a woodburning stove? Yes NoDo you have any of the following safety equipment?Smoke Detector Yes NoDead Bolt Locks Yes NoFire Extinguisher Yes NoSecurity System (Local Sounding Only) Yes NoSecurity System (Dials In To Security Company) Yes No

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